Hordeolum and chalazion treatment The full gamut

Leonid Skorin Jr, OD, DO, FAAO, FAOCO
Hordeolum and chalazion treatment
The full gamut
Hordeola and chalazia are some of the most
common inflammatory eyelid disorders
encountered in optometric practice. Many
patients try to treat these lesions conservatively
using home remedies or over-the-counter
medication. Often, such treatment is efficacious
and the lesion resolves as intended. In those
individuals where the condition persists, the
optometrist may be consulted for more definitive
care.
Internal hordeolum
Signs and symptoms
An internal hordeolum (meibomian stye) is a
small abscess caused by an acute staphylococcal
infection of the meibomian glands of the tarsus
(Figure 1) 1 . These lesions may occur in
conjunction with acute or chronic blepharitis.
They point posteriorly and often rupture
spontaneously and drain through the
conjunctival surface 2 . A specific change in
meibomian gland secretion has been linked to
internal hordeolum formation 3 .
Figure 1 Internal hordeolum
scrubs with a mild shampoo also helps to remove
any debris, which may have accumulated on the
eyelid margin surface, and in those patients with
blepharitis. Because staphylococcus species are
usually the underlying causes of the infection,
primary medical therapy should consist of a
penicillinase-resistant penicillin such as
dicloxacillin. Dosages of 125mg to 250mg every
six hours, usually result in prompt resolution of
the infection 5 . Patients who are allergic to
penicillin can try oral erythromycin,
chloramphenicol or the aminoglycosides 2 . Finally,
in cases which resist medical therapy, incision
and drainage using a sterile needle or blade may
be necessary 5 .
External hordeolum
Signs and symptoms
An external hordeolum (common stye) is a
purulent inflammation of infected eyelash
follicles and surrounding sebaceous (Zeis) and
apocrine (Moll) glands of the lid margin
(Figure 2) 4 . It is usually due to a staphylococcal
infection and may be associated with
staphylococcal blepharitis. The lesions are often
associated with fatigue, poor diet and stress and
can be recurrent 6 .
External hordeola present as tender inflamed
swellings in the lid margin, which points
times a day during the acute phase and
continued twice daily for one week thereafter,
may prove helpful, especially in preventing the
infection spreading to the surrounding lash
follicles 5,8 . Systemic antibiotics such as oral
erythromycin or dicloxacillin may be necessary if
there is severe preseptal cellulitis 1 . Finally, for
resistant lesions, an incision can be made with a
sterile needle or blade into the area of pointing,
which allows the abscess cavity to drain 6,7 .
Chalazion
Signs and symptoms
A chalazion is a localised lipogranulomatous
inflammatory response involving the sebaceous
glands (meibomian or Zeis) of the eyelid. It
occurs secondary to obstruction of the gland
duct 4 . The obstruction can be the result of
inflammation or infection (acne rosacea or
seborrheic dermatitis), or of neoplastic lesions
(sebaceous gland carcinoma or Merkel cell
tumour) of the lid margin 9 . Chalazia occur
spontaneously or may follow an episode of acute
internal hordeolum.
The onset and progression of this lesion is
usually slow and associated with few symptoms.
They are more common in the upper lid,
appearing as a hard, immobile, painless,
roundish lump in the tarsal plate 1,10 (Figure 3).
The chalazion may produce pain if it grows very
large and cause distention of sensory nerve
endings. An upper lid chalazion may press on the
cornea and cause blurred vision from induced
astigmatism 11 . At least 25% of chalazia resolve
spontaneously within six months of onset, but
most require treatment 12 .
These lesions characteristically occur abruptly
with a painful swelling and erythema, often of
the entire eyelid. Eversion of the eyelid will
show a more localised lesion and in advanced
cases, a yellowish nodule can be seen through
the tarsal conjunctival surface 2 . The eyelid
margin surrounding the orifice of the involved
meibomian gland is usually inflamed. Any
secretions within the orifice are purulent when
expressed. The inflammation can spread to other
adjacent glands or to the apposing or
contralateral eyelid 4 . Recurrences are common,
especially if any underlying conjunctivitis or
blepharitis is not adequately treated.
Treatment
Because the infection is deep within the lid
tissue, the topical application of antibiotics is
usually ineffective 5 . The patient should be
instructed to apply hot compresses for five to 10
minutes, two to four times a day, in order to
liquefy the stagnant secretions and facilitate
drainage through the meibomian orifice 2 . Lid
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Figure 2 External hordeolum
anteriorly through the skin 1 . In most cases, the
lesion drains spontaneously within three or four
days after pointing 5 . More than one lesion may
be present and, occasionally, minute abscesses
can involve the entire lid margin. Pain,
particularly on manipulation of the eyelid, is the
most notable symptom. As with any skin abscess,
the nodule is usually red and warm to the touch.
Treatment
Hot compresses several times a day accelerate
the pointing of the lesion and its spontaneous
drainage. If an eyelash is seen to extend from
the involved lesion, then epilation of the lash
can initiate drainage of the lesion by creating an
effective drainage channel 7 . Bacitracin or
erythromycin antibiotic ointment, applied four
Figure 3 Chalazion
Treatment
Topically or systemically administered antibiotics
are ineffective because the lesion is not
infectious in origin 13 . The application of hot
compresses followed by gentle massage may
evacuate stagnant secretions. This prevents
further chalazion formation and encourages
drainage along the duct of the involved
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gland – which may be of benefit if the lesion is
small 2 . Vigorous massage can cause further
extravasation of the meibomian secretions into
the surrounding tissue, spreading the
granulomatous inflammation 2 . Regrettably, this
treatment is not very effective, resolving only
around 40% of these lesions 13,14 .
Chalazia which fail to resolve with
conservative management may be treated with an
intralesional injection of steroid 14 . This technique
increases the resolution rate to 80%, while
combining the conservative therapy with steroid
injection increases the resolution rate to 90% 14 .
Since the chalazion is encapsulated by
connective tissue, there is little room for
space-occupying steroid medication. Therefore,
a steroid of increased concentration such as
triamcinolone acetomide (Kenalog-40), a
40mg/ml concentration works well since
only a 0.10-0.20cc dose needs to be injected
(Figure 4).
The chalazia can be injected through the skin
surface or the conjunctival side using a 1ml
tuberculin syringe with a 27-gauge or 30-gauge
needle. The steroid suspension should be
injected into the centre of the lesion. If injection
is performed from the conjunctival side, several
drops of a topical anaesthetic to numb the
puncture site and minimise blinking. Injection
through the skin surface of the eyelid requires no
anaesthesia. Some practitioners prefer to use a
chalazion clamp, but this is not always necessary.
Chalazia typically resolve within one or two weeks
after a single injection, but larger chalazia may
require a second injection.
This technique is safe and effective. There has
been one reported case of a serious complication
resulting in both retinal and choroidal vascular
occlusion from embolisation of the injected
steroid 15 . To minimise the chances of this
occurring, practitioners should aspirate for blood
before injecting, take care to inject slowly, and
avoid heavy digital pressure during and after
injection 16 . Other less serious complications
include pain on injection, depigmentation of the
eyelid at the injection site, temporary skin
atrophy and subcutaneous white (steroid)
deposits (Figure 5) 5 .
Figure 5
Subcutaneous white (steroid) deposits
after intralesional triamcinolone injection
The most reliable therapy involves surgical
excision of the affected meibomian gland
(Figures 6-9). The surrounding eyelid tissue
needs to be injected with the anaesthetic
Figure 9
Forceps pointing to excised gland
after it has been cleaned of debris
Xylocaine (lidocaine). The eyelid is everted and a
traction suture is placed through the eyelid
margin. Then a chalazion clamp is positioned
over the lesion. This helps stabilise the eyelid
and assists in hemostasis. A surgical #11 or #15
straight blade or a circular trephine blade is
used to incise the involved meibomian gland
through the conjunctival surface. A curette is
then used to scrape out the chronic
granulomatous debris.
The chalazion clamp and traction suture are
removed and the eyelid is repositioned. Digital
pressure is applied until all the bleeding has
stopped. The eye is treated with antibiotic
ointment, which the patient should continue to
use two times a day for five to seven days. The
patient should be re-evaluated after about two
weeks.
There are usually few complications from this
surgery. The eyelid may be swollen and
discoloured after the surgery for several days to
one week. Occasionally, a subconjunctival
haemorrhage can also develop, but this will
resolve without incident (Figure 10). On rare
occasions, the chalazion may recur if the
surgical excision was incomplete.
Figure 6
Injection of eyelid with the anaesthetic,
Xylocaine (lidocaine)
Figure 4
Setup for steroid injection for chalazia
Locally injected steroid suspension works
because a chalazion is composed of steroidsensitive
histocytes, multi-nucleated giant cells,
lymphocytes, plasma cells, polymorphonuclear
leukocytes, and eosinophils 4 . The injected steroid
suppresses additional inflammatory cells and
impedes chronic fibrosis.
Figure 7
Chalazion clamp and traction suture in place
Figure 8
Currette adjacent to granulomatous debris
scraped from inside the meibomian gland
Figure 10
Child with eyelid ecchymosis and
subconjunctival haemorrhage after surgical
excision of chalazion
Pyogenic granuloma
Signs and symptoms
A pyogenic granuloma may be seen after trauma
or surgery, or may form over inflammatory
lesions, such as chalazia. These nodules occur
rarely in the anophthalmic socket following
enucleation of the eye and at the margin of
corneal transplants 17 .
These lesions occur on the conjunctival side
of the eyelid and are fleshy, red, usually sessile
with a palpable rigid either non-tender or
moderately tender presentation (Figure 11).
Microscopically, a pyogenic granuloma is
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June 28, 2002 OT
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Figure 11
Pyogenic granuloma
composed of granulation tissue with chronic
inflammatory cells, fibroblasts, and endothelial
cells of budding capillaries. The term pyogenic
granuloma is actually a misnomer since the
lesion is neither pyogenic nor granulomatous 18 .
Treatment
Treatment consists of complete excision and
curettement of any underlying inflammatory
eyelid lesion such as a chalazion. Pathologic
evaluation is also recommended, since several
other benign and malignant neoplasms, such as
Kaposi’s sarcoma, may simulate pyogenic
granuloma 17 .
About the author
Dr Leonid Skorin Jr is a licensed optometrist and
a board-certified ophthalmologist. He is
fellowship trained in neuro-ophthalmology. He
has numerous publications and has lectured
internationally.
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www.optometry.co.uk
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